3. Observed Clinical Process

1. 5 Dimensions of Observed Clinical Process

1.1. Perspective of Observation: Who is doing the observation?

• Researcher (trained observer)

• Clinician (A professional involved in the process (e.g., a therapist)).

• Client/help-seekers (participant-index person)

• Significant others (e.g., family member)

1.2. Person/Focus: What element of the clinical process is studied?

• Client or client system (individual, family)

• Clinician or clinical system (therapist/agency)

• Interaction of client and clinician (relationship, “fit”)

1.3. Aspect of Behavior: What kind of behavior or process is studied?

• Intention/Form: This is about why someone says or does something, or the structure of their speech (like making a request or asking a question).

• Content: This refers to what they are actually talking about – the main ideas or topics.

• Style: This focuses on how they express themselves, such as how long they talk, how often they say something, how intensely they speak, or their body language.

• Quality: This evaluates how well they do or say something, looking at if it's accurate, appropriate, or skillful.

1.4. Unit Level: At what level or “resolution” is the process studied? (selected units)

• Sentence (idea unit): Looking at just one idea or thought.

• Action/Speaking Turn (interaction unit): Observing each time someone speaks or acts, and how others respond.

• Episodes (topic/task unit): Focusing on a series of interactions related to a specific topic or task within a meeting.

• Occasion ("scene" unit): Observing an entire meeting or session.

• Relationship (interpersonal units): Looking at the complete history and connection between two people.

• Organization (institution unit): Studying a whole institution or system, like a clinic, and how it's structured.

• Person (self unit): Analyzing an individual's overall beliefs, characteristics, and life experiences.

1.5. Sequential Phase: what happened before, during, and after the unit)?

This section looks at the timeline of what is being observed:

• Context ("antecedent"): What happened right before the observed event or behavior.

• Process ("behaviors"): The actual event or behavior being studied at that moment.

• Effects ("consequences"): What happened right after the observed event or behavior (like the results or outcomes).

2. How to Do Observation?

2.1. Take Notes On:

• Specific behaviors (eye contact, behavior during test that clarifies attention, focus, attempt, level of anxiety, etc.).

• Comments (relevant or irrelevant).

2.2. Categorize behaviors and comments into recurrent themes (e.g., behaviors indicative of persistence, inattention, positive self-concept, etc).

2.3. Make interconnections between interpreted themes to understand the total profile of the individual.

• Example: If ten behaviors seem contradictory, propose a hypothesis about why those behaviors differ and how they relate to the test (see Rapid Reference 4.1, 4.2).

3. Rapid Reference 4.1: Samples of Behaviors, Interpretations, and How to Combine Them into a Statement

3.1. Interpretations:

• Foot tapping, fidgety hands, hair twirling \rightarrow Anxiety.

• Slouching in chair, averted gaze, silence \rightarrow Resistance.

• Stacking blocks, spinning puzzle pieces, doodling with pencil on Coding booklet \rightarrow Inattention and distractibility.

3.2. Example Statements in Report:

• José appeared anxious on tasks that required verbal responses, evidenced by foot tapping, fidgety hands, and hair twirling.

• Michelle was resistant to the assessment. Throughout the evaluation, she slouched in her chair and averted her gaze, often responding with silence.

• Lan had trouble maintaining focus during nonverbal items, easily distracted by stimuli; when he copied a block design, he stacked blocks, spun pieces, and doodled instead of following directions.

4. Combine Paragraph of Interpretive Hypothesis and Specific Behaviors

• 4.1. Interpretive Hypotheses (Figure 4.1) + Specific Behaviors \rightarrow Integrated Paragraph

  • Interpretive Hypotheses: These are explanations or inferences based on observed behaviors, providing a broader understanding of an individual's characteristics or processes.

    • Example (Andy):

      • Andy showed a strong ability to concentrate and remained focused throughout the evaluation.

  • Specific Behaviors: These are the concrete, observable actions or statements made by an individual during an observation or assessment.

    • Example (Andy):

      • Andy attended well on tasks despite finding some boring; persisted on difficult tasks; when unsure, he said "I don't know" and continued to the next item.

  • Integrated Paragraph: This is a combined narrative that weaves together the interpretive hypotheses with the specific behaviors to form a comprehensive description.

    • Example (Andy):

      • Andy showed strong concentration and stamina, maintaining focus on all tasks, persisting through challenging ones, and continuing after admitting uncertainty.

4.2. Figure 4.1 demonstrates how to blend interpretive hypotheses with concrete behaviors to form the narrative of the report.

5. Example: Contradicting Interpretive Hypotheses and Integrations

5.1. Diego was calm and even-tempered, with an even pace and pleasant grin during most of the evaluation.

5.2. Contradicting Behaviors: During the Arithmetic subtest, he spoke faster and rubbed his forehead repeatedly, suggesting anxiety.

5.3. Integrated Paragraph (Figure 4.2): Diego was generally calm, but mathematics elicited anxiety in challenging items, evidenced by increased speech rate and forehead rubbing.

6. Dos and Don’ts of Writing Behavioral Observations

7. Possible Topics to Include in Behavioral Observations Section of Report

8. Physical Appearance

8.1. Clues about physical, psychological, and neurological functioning.

8.2. Aspects: height, weight, build; grooming.

8.3. Senses Integration:

• Sight: Appearance, gait, movement.

• Hear: How the person talks (loud/soft).

• Smell: Odor (e.g., strong alcohol).

• Touch: Grip when shaking hands or writing.

8.4. Appearance should be appropriate or consistent with age, social position, education, economic status, and subculture.

8.5. Physical handicaps or adornments; hygiene.

8.6. Hygiene can be associated with psychological disturbance, especially when severe.

9. Ease of Establishing and Maintaining Rapport

9.1. Rapport varies across individuals; some warm up quickly, others require more time.

9.2. Is the person friendly, abrupt, shy, frightened, cooperative, aggressive, or respectful?

9.3. Is rapport disrupted? Consider differing values, beliefs, and behaviors.

10. Communication

10.1. Speech features affect understandability: speed, pitch, volume, rhythm.

10.2. Accents and regional dialects can affect comprehension.

10.3. Some people speak spontaneously; others respond only to direct questions.

10.4. Observe pronunciation, word use, grammar, and conversational maintenance.

10.5. Non-verbal communication (gestures) should be noted.

11. Response to Failures

11.1. Observe reactions to difficult items: some persevere, some give up, some quit.

11.2. Observe how confidence affects responses to hard items.

12. Response to Feedback

12.1. Reactions to praise and correction vary (some smile; some ignore praise).

12.2. Note what type of reinforcement motivates effort.

12.3. Some individuals learn from feedback; others do not benefit from correction.

13. Attention

13.1. Attention may waver over the assessment; monitor attention span and self-management.

13.2. Observe attention to different instructions and tasks.

13.3. Note distractions that disrupt focus.

14. Activity Level

14.1. Observe movements before, during, and after tests for clues about anxiety, boredom, impulsivity, and coordination.

14.2. Is activity level developmentally appropriate?

14.3. Posture can reflect self-concept.

15. Mood & Temperament

15.1. Brooks & Goldstein (2001) patterns:

• Easy child: Cooperative, pleasant, may request more time.

• Slow-to-warm-up: Dislikes unfamiliar experiences; needs more acclimation time.

• Difficult child: Attention, motivation, and self-regulation challenges; easily frustrated by mistakes.

16. Problem-Solving Strategies

16.1. How a person attempts to solve problems and the strategies used:

• Try approach that doesn’t work; quickly change approach and try another.

• Examine problem carefully and proceed cautiously step by step.

17. Attitude Toward Self

17.1. People reveal feelings about performance via:

• Facial expressions (e.g., grimace, blushing, satisfied).

• Self-statements (self-deprecating, derogatory, or boastful).

18. Unusual Mannerisms & Habits

18.1. Some examinees may display unusual behaviors (e.g., flicking dust, covering ears/eyes, spinning pencils).

19. Observing in Non-Testing Environment (natural setting)

19.1. Record a variety of behaviors or focus on a few problematic behaviors.

19.2. Define key components of observation:

• What behaviors will be observed?

• Where will observation take place?

• How will behaviors be recorded?

19.3. Use clear, concise definitions to distinguish target behaviors from similar ones.

19.4. List several targeted behaviors to capture the intended picture (see Rapid Reference 4.3; 4.6).

20. Conduct: Rapid References and Behavioral Targets

20.1. Rapid Reference 4.3: Sample Behaviors Targeted during Observation (Social Competence, Depression, Noncompliance, etc.)

• Examples (selected): Social competence: cooperative play, talking; Depression: flat affect; Noncompliance: arguing; Aggression; Turn taking; Yelling; Teasing; etc.

20.2. Source: Kamphaus and Frick, 1996; Adapted with permission.

21. Behavioral Assessment System for Children - Student Observation System (BASC-SOS)

21.1. Use in classroom settings (Rapid Reference 4.6).

21.2. Categories and Definitions:

• Response to Teacher/Lesson (appropriate academic behaviors involving teacher/class).

• Peer Interaction (appropriate interactions with peers).

• Work on School Subjects (academic work done independently).

• Transition Movement (non-disruptive movement between activities).

• Inappropriate Movement (unrelated motor behaviors).

• Inattention (inattentive but not disruptive).

• Inappropriate Vocalization (disruptive talking).

• Somatization (physical symptoms/complaints).

• Repetitive Motor Movements (repetitive, seemingly unrewarded).

• Aggression (harmful behaviors toward others or property).

• Example of Specific Behaviors: follows directions; raises hand; contributes to class; waiting for help; plays with others; etc.

21.3. Additional examples include fidgeting, note passing, daydreaming, doodling, looking around room, etc.; categories cover a broad spectrum of classroom behaviors.

21.4. Source: Reynolds & Kamphaus, 1992; Adapted with permission.

22. Mental Status Examination (MSE)

The Mental Status Examination (MSE) is like a snapshot of a person's current mental state. It's a way for a professional to observe and describe different aspects of someone's thinking, mood, and behavior right at that moment. Unlike a standardized test with scores, it's more about subjective judgment and can be used flexibly, often combined with other information.

23. MSE Components

24. Appearance (MSE Component)

24.1. Description of general look, dress, and hygiene.

24.2. Should be appropriate for age, social position, education, economic status, subculture.

24.3. Consider physical handicaps or adornments; indicators of self-perception and social conformity.

24.4. Hygiene often associated with psychological disturbance when severe.

25. Behavior (MSE Component)

25.1. Observable conduct during the interview; includes both verbal and non-verbal aspects.

25.2. Verbal:

• Speech patterns (tone, pace, forcefulness).

• Flow (rapid/pressured/controlled).

• Language, pronunciation, grammar, slang.

25.3. Non-Verbal:

• Posture, facial expression, eye contact.

• Motor activity (fidgeting, restlessness, pacing, nail-biting, tapping), movements.

• General attitude (cooperative, suspicious, anxious, friendly, attentive, etc.).

25.4. Bizarre behavior may suggest significant disturbance.

26. Orientation (MSE Component)

26.1. Intact orientation to person, place, time (x3).

26.2. Disorientation may indicate organic conditions.

26.3. Orientation problems more common with time/place than with person (dissociative states, severe impairments).

27. Memory (MSE Component)

27.1. Evaluation of memory by levels:

• Immediate: Recall within \sim 10 seconds of presentation.

• Recent: Recall beyond 10 seconds but within the recent past.

• Remote: Significant life events (illnesses, hospitalizations, past employment, places lived, durations).

27.2. Disturbances may indicate organic or functional psychopathology.

28. Sensorium (MSE Component)

28.1. Refers to physiological receptive systems: hearing, vision, touch, smell.

28.2. Also reflects general attention and concentration ability.

28.3. Impairments often signal organic conditions.

29. Mood & Affect (MSE Component)

29.1. Mood: Prevailing emotional state during interview (e.g., anger, irritability, elation, anxiety, fear, depression, sadness, apathy).

29.2. Affect: Range of emotions expressed during interview; normal affect adapts to content; flattened affect suggests impairment (e.g., schizophrenia).

30. Intellectual Functioning (MSE Component)

30.1. Assessed via verbal ability, vocabulary, education/occupation status.

30.2. Include reading/writing, general knowledge, arithmetic, interpretation of proverbs.

30.3. Low function relative to education/experience suggests impairment.

31. Perceptual Process (MSE Component)

31.1. Refers to five senses and how the person perceives the world.

31.2. Hallucinations are key: perception without external stimuli (auditory, visual, etc.).

31.3. Gustatory, olfactory, tactile hallucinations more often linked to organic conditions; visual/auditory can occur in organic or functional disorders.

32. Thought Content (MSE Component)

32.1. What the person talks about spontaneously; concerns and focus on a topic.

32.2. Primary deficits: delusions (fixed, unchangeable beliefs not culturally approved; persecutory or grandiose).

32.3. Obsessions (repetitive ideas), compulsions, phobias, or depersonalization/unreality.

32.4. Delusional thinking can be present in psychotic disorders but may appear in functional and organic conditions.

33. Thought Process (MSE Component)

33.1. Stream of consciousness; language process reflects underlying thought.

33.2. Defects in thought process:

• Underproductivity: Mute or impoverished verbal output.

• Blocking: Gaps in speech; may indicate difficulty with content or concentration.

33.3. Abnormal patterns:

• Flight of ideas: Rapid, illogical linking of ideas; often seen in mania.

• Loosening of associations: Rambling, circumstantiality, tangentiality, non sequiturs.

34. Insight (MSE Component)

34.1. Psychological mindedness; awareness of changes in feelings and behavior; ability to relate behavior to past events and to hypothesize.

34.2. Focus on: whether individual can verbalize problems, whether they blame others/fate, and whether they relate behavior to historical/environmental antecedents.

35. Judgment (MSE Component)

35.1. Decision-making and ability to handle daily living tasks.

35.2. Typical patterns: impulsive vs. rational vs. methodological vs. trial-and-error.

35.3. Noting excessive risk-taking or failure to account for important factors.

35.4. Impairments may occur in psychoses, organic conditions, or under high stress in low-functioning individuals.

36. References

• Lichtenberger, et al. (2004). Essentials of Assessment Report Writing. Canada: John Wiley & Sons, Inc.

• Barker, C., Pistrang, N., & Elliott, R. (1994). Research Methods in Clinical and Counselling Psychology. Singapore: John Wiley & Sons.

• Maloney, M., Ward, M. (1976). A Conceptual Approach. New York: Oxford University Press.